COMPREHENSIVE HEALTH APPROACH TO FIGHT CHAGAS DISEASECONTINENT
COUNTRY
HEALTH FOCUS
AREAS OF INTEREST
HEALTH SYSTEM FOCUS
Central America
Guatemala
Infectious Disease
Health promotion, disease prevention, cross-sector collaboration
Community delivery
AN ECO-HEALTH APPROACH TO FIGHT CHAGAS DISEASE, GUATEMALA
Sustainable prevention of Chagas’ disease was achieved by reducing the risk of household infestation by
Triatomine bugs through empowerment of communities to use locally available materials for home improvement
and removal of animals from the household.
Authors: Maria Isabel Irurita (Universidad Icesi) and Lina Pinto (York University, Canada)
This case study forms part of the Social Innovation in Health Initiative Case Collection.
The Social Innovation in Health Initiative (SIHI) is a global network of individuals, organisations and institutions collaborating to advance social innovation in health
This case study was prepared by CIDEIM and Universidad Icesi. Research was conducted in 2017. This
account reflects the stage of social innovation at that time.
SIHI Academic Advisory Panel: Prof Lenore Manderson, Dr Lindi van Niekerk, Rachel Chater
For more information on SIHI and to read other cases in the SIHI Case Collection, visit www.socialinnovationinhealth.org or email [email protected].
SUGGESTED CITATION: Irurita, M. & Pinto, L. (2018). An eco-health approach to fight chagas disease in Guatemala and beyond. Social
Innovation in Health Initiative Case Collection. [Online] WHO, Geneva: Social Innovation in Health Initiative, Available at: https://socialinnovationinhealth.org/case-studies/eco-health-approach-to-fight-chagas-
disease/
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CONTENTS
ABBREVIATIONS ............................................................................................................................. 3
1. CASE INTRODUCTION ........................................................................................................ 4
2. INNOVATION AT A GLANCE ............................................................................................. 5
3. CHALLENGES .......................................................................................................................... 6
4. INNOVATION IN INTERVENTION AND IMPLEMENTATION .................................. 7
5. ORGANISATION AND PEOPLE ........................................................................................ 8
5.1. COSTS CONSIDERATIONS ........................................................................................... 9
6. OUTPUTS AND OUTCOMES ............................................................................................. 10
7. SUSTAINABILITY and scalability ..................................................................................... 11
8. KEY LESSONS ........................................................................................................................ 12
9. REFERENCE LIST .................................................................................................................. 14
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ABBREVIATIONS
USAC Universidad de San Carlos
WHO / OMS World Health Organization / Organización Mundial de la Salud
JICA Japan International Cooperation Agency (Japan)
PAHO/OPS Pan American Health Organization / Organización Panamericana de la Salud
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1. CASE INTRODUCTION The case presented here takes place in Guatemala
in Central America, a region understood to
constitute a ´hot spot´ for Chagas disease (WHO,
n.d). Based on the number of deaths per annum,
Chagas is the deadliest parasitic disease in Latin
America. It affects around 8 million people, causing
an estimated 10,000 deaths each year particularly
among populations living in poverty (WHO, 2017).
This disease is caused by the parasite Trypanosoma
cruzi, which is transmitted by an insect (Triatomine
bug) that in Guatemala is called a chinche. Chagas
disease is associated with conditions of extreme
poverty and neglect, because the insect
transmitting the parasite colonizes households in
poor rural communities where cheap, readily
accessible materials such as adobe, wood and
palm leaves are used for construction. The insect
feeds on the blood of dogs, birds, rodents, other
animals and humans. It hides inside homes in
crevices and cracks in adobe or wooden walls and
poorly finished floors, and in roofs made of palm
leaves.
The University-based project described here was
initiated through research led by Dr. Maria Carlota
Monroy and Dr. Antonieta Rodas, from the
Laboratory of Applied Entomology and
Parasitology (LENAP) at Universidad de San
Carlos in Guatemala. The research, undertaken by
the team from 2004, identified 17 risk factors for
infestation of households by vectors. Three of
these risk factors were related to the quality of the
homes and were susceptible to intervention: the
quality of flooring, the quality of the walls, and the
presence and rearing of animals inside the homes.
The eco-health approach developed by the
researchers, and backed financially by
international donors including IDRC (International
Development Research Centre), consists of two
components: 1) the design of a strategy to fill
cracks in the floors and walls using locally available
materials; and 2) training of leaders and members
of rural communities on how to repair and improve
their own homes and to adopt the healthier
practice of raising animals outside of the
household. For the first component of the
intervention, the team experimented with different
materials and received professional guidance to
identify ways of improving walls and floors. This
led to finding that volcanic ash and sand provided
the best mix to keep bugs from colonising homes.
The eco-health approach was implemented
primarily in the department of Jutiapa, an endemic
zone for Chagas disease bordering El Salvador and
the Pacific Ocean. The approach has effectively
reduced the rates of infestation of the Triatomine
bug in the region but more importantly, it has
impacted the ability of local communities to
combat the disease permanently, by creating
awareness about ways of reducing the risks and by
training a good number of community leaders as
health workers, who continued to monitor their
communities after the university based team left
the areas.
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2. INNOVATION AT A GLANCE Project Details
Project name Eco-health, an integral approach to the control of Chagas Disease
Founding year 2004
Founder’s name Dr. Maria Carlota Monroy and Dr. Antonieta Rodas
Nationality of funders Guatemala
Organisations involved Laboratory of Applied Entomology and Parasitology (LENAP), Universidad de San Carlos
Organisational structure Research and Action Laboratory within a private university
Innovation Value
Value proposition Solutions to health problems must be developed according to the cultural and socio-economic context of the intended beneficiaries, involving them in each step of their implementation.
Beneficiaries Rural populations in Guatemala and other Central American countries
Key components Home improvement strategy (focused on improving and polishing floors and walls and better rearing of animals) to eliminate the presence of the Chagas vector, based on risk factors, with the use of local materials.
Operational Details
Main income streams International donors such as IDRC (Canadá) and support from the Universidad de San Carlos with infrastructure and personnel.
Cost per person served Approximately US$100 per house
Scale and Transferability
Operational coverage Currently operating on a national scale and with occasional project based presence in other countries including México, Nicaragua, Salvador and Honduras
Local commitment Working together with the Comapa Health Centre, Área de Salud de Jutiapa (Jutiapa Health Area), the Comapa midwives, Visión Mundial (World Vision), Ibermed
Scalability Eco-health approach has all the elements needed and the evidence base to become a fully funded, first national and then international, strategy for the elimination of Chagas.
Sustainability
Key learnings from this approach need to be embedded into local communities, to be taken into account when building new homes and repairing existing ones. Learnings also need to be translated into an educational strategy aimed and designed at different levels and professions.
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3. CHALLENGES
Chagas disease or American tripanosomiasis is a
disabling and potentially fatal illness that affects
vital organs such as the heart, the nervous system
and the intestinal tract. It is caused by the parasite
Trypanosoma cruzi, which is transmitted by an insect
(Triatoma dimidiata). Both the Central American
Region (where Guatemala is located) and the Gran
Chaco region in South America are endemic zones
for the illness (Solorzano, 2016). Infection may not
be identified for many years, until an infected
person has a heart attack in the midst of their
normal activities such as cultivating their plots. The
usual symptoms are not necessarily alarming
(fatigue, tiredness, lack of energy) but infection
leads to an enlarged heart (cardiomegaly) which
can result in death (Stevens et al., 2015).
Guatemala is a country divided in 22 departments,
comprising a total of 337 municipalities. The
Triatoma dimidiata exists in 21 of the 22
departments and is endemic in 13. In the
department of Jutiapa its presence appears to be
particularly strong, according to evidence
collected by the Jutiapa Health Area. Comapa
appears to be the municipality most affected
(Chavez, 2015).
From the second half of the twentieth century,
infestation rates have remained high and levels of
awareness about the disease low (Solorzano,
2016). The country has participated in various
approaches to control Chagas disease, including
spraying with different insecticides with allegedly
controversial results, and the creation of Iniciativa
de los Países de America Central para la
Interrupción de la Transmisión Vectorial y
Transfusional de la Enfermedad de Chagas IPCA,
set up in 1997 jointly with other Central American
countries and extended to Mexico in 2013 (so
changing its name to IPCAM). This is a space for
technical discussions about new control and
prevention strategies.
From 2000 to 2014, with the financial and
technical support of the Japan International
Cooperation Agency (JICA), a massive spraying
campaign and strategy was implemented in four
Central American countries, including Guatemala.
It aimed at controlling the Rhodnius prolixus and
at reducing significantly Triatoma dimidiata, both
insects associated with the transmission of the
Chagas parasite. Rhodnius prolixus was eliminated
in several countries although it still exists minimally
in Nicaragua. While the infestation levels of the
Triatoma dimidiata were significantly reduced, the
ecological niche of the former were used and
appropriated by the latter, making it necessary to
expand efforts to fight the bug, which was
increasingly resistant to insecticides (Solorzano
2016).
The chinches, as the host bug is known, feeds on
blood from dogs, hens, rodents and humans, and
resides (and can hibernate for up to six months) in
the cracks of the walls and floors of local homes
and structures (Monroy et al., 2009). For this
reason, Chagas disease is associated with poverty
and with often neglected and underserved
populations.
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4. INNOVATION IN INTERVENTION AND IMPLEMENTATION
The main element of the solution was a home
improvement programme that filled cracks in the
floors and walls using a mix of locally available
materials, while at the same time raising awareness
and training community leaders and members to
repair their own homes and contribute to
behavioral and cultural changes (such as rearing
animals outside the homes) to eliminate the
vector. Rather than attempting to control the
transmission of the vector through insecticide
spraying, this strategy aims at changing the
cultural and physical conditions that perpetuate
the problem.
Dr. Monroy, co-founder and lead of the eco-health
approach to the control of the Chagas disease,
recognised that trying to treat Chagas disease
through spraying was not effective. Gilbert Erazo,
Chagas supervisor for the Department of Jutiapa,
remembers there were large numbers of the
vector in many houses: “It was normal for us back
in 2004 to find 100, 200 chinches per house.” Dr.
Monroy began to research the risk factors
associated with the existence of the vector. Three
factors stood out: the quality of the floor, the
quality of the walls, and the presence and rearing
of animals inside the homes. Addressing these
three factors would make the homes “refractory,”
that is, immune to the occasional presence of
specific bugs or to other environmental changes.
This is how the home improvement programme
was conceptualised, developed and initiated by
the researchers, who experimented with different
materials and professionals (such as architects,
engineers, and environmentalists) to find ways of
improving walls and floors. They realised that
materials most widely available in their
surroundings, such as volcanic ash and sand,
provided the best mix to keep bugs at bay. Eco-
friendly, local and organic materials, instead of
massively produced cement, provided the solid
foundations for the home improvement strategy
that has been implemented ever since.
Dr. Monroy highlights four aspects of innovation
with regards to the implementation of the
strategy. First, their approach was based on well-
researched risk factors. Having managed to
identify and address three factors that are subject
to changes and are related to the quality of the
homes, this team was convinced that the long-
term benefits of their home improvement
approach would outweigh and outperform the
short term gains of chemical sprayings: “By
focusing on addressing risk factors, we are dealing
with the root causes of this problem and not
simply battling its effects,” Dr. Monroy asserts.
Secondly, Dr. Monroy recognizes that working
outside her professional boundaries has also been
a critical aspect for their success: “From the
moment we identified the three factors we were
going to focus on, we started opening up our
vision to consult with and include other
professionals such as engineers, architects,
doctors, sociologists and anthropologists. Our
analysis was multidisciplinary and so was our
intervention. Working across professions and
disciplines wasn’t always easy, but it was worth the
effort.” Moreover, the eco-health approach is not
just multidisciplinary but also intersectoral. When
a new geographical area is prioritised and
scheduled for the home improvement
intervention, many people interact and contribute
to planning and the delivery of the strategy: a team
from the national programme for the prevention of
Chagas and other agents from the Ministry of
Health, the health team of the regional
government, public and private universities,
international NGOs, and even city mayors have
contributed their skills and resources. While
conducting the fieldwork for this case study, three
interviewees (namely Dr. Monroy, the Mayor of
Comapa Mr. Estuardo Vasquez, and the Chagas
supervisor for the Jutiapa Department Mr. Gilbert
Erazo) all spoke of their collaborative spirit and
experience.
The eco-health approach to the control and
prevention of Chagas can be categorised as
community-owned. This is evident in several ways.
To start, the home improvement strategy respects
the original design and internal space of the
houses. It takes into account Mayan cultural
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heritage of these designs and construction, where
windows do not play a dominant role. The strategy
has therefore focused on polishing and filling gaps
in the walls as they are, even if they are uneven.
The strategy has also emphasised the importance
of having neat floors, which are polished, filled and
shone with the organic, local materials that work
as natural repellents. Communities own this home
improvement strategy both by adapting it to the
shapes and original designs of their homes and by
using and exploiting local widely available
materials that had previously been underused.
A fourth aspect was especially innovative. Dr.
Monroy affirms that in delivering their solution,
many people benefited and became ambassadors
of their approach, not just executors or facilitators.
This was the case, for example, for many women,
and for young students who joined their laboratory
as junior researchers while still undertaking their
undergraduate degrees. Most have pursued
careers in science and continued postgraduate
degrees, but they are still closely related to the
laboratory and support it in different ways. This
has also been the case with many of the field
technicians who were trained over the years.
Laboratory staff acknowledge that their role is to
train people from local communities so they can
become architects of their own progress. As floors
need to be repaired every 20 years, and walls need
to be re-done after nine years, it is important to
embed locally the abilities to mix the materials and
to implement the improvements. Following this
line, Belter Alcántara, field technician from LENAP,
commented: “I am convinced that when this
solution is owned by the communities, when they
participate from preparing the materials and from
doing the improvements by themselves, this
solution stays there, communities can use it
whenever they need to, and in this way it becomes
more effective and long lasting.”
Beneficiaries who were consulted and interviewed
mentioned other ways in which the team´s
implementation of their solution differed from
other approaches: “They did not just come to
teach us about the chinches and how to eliminate
them by improving our homes (…) they also took
blood samples, then came back with the results. To
those infected they facilitated access to the
treatment, and they gave them groceries so
patients could recover more quickly,” says Doña
Cristina, beneficiary and now advocate of the
home improvement programme and community
leader in Almolonga, Jutiapa.
This team also assists people undergoing
treatment by leveraging support from other
institutions. In this regard, Dr. Monroy commented:
“You can always do a little bit more for these
families. Consider for example our last
collaboration. We partnered with a private school
in New York city. Primary students there are
fundraising, so we can buy food and market
provisions for patients who are undergoing
treatment here in Guatemala. The medical
treatment is very strong; it lasts two months, and
you can only benefit from it if you are well fed.”
Addressing risk factors, working collaboratively
across sectors and disciplines, making sure that
communities take a lead role in the preparation
and delivery of the solution, preparing field
technicians so they become facilitators and
trainers of many more, and finally extending
activities to provide stronger support to the
affected communities, have all contributed to the
innovativeness and effectiveness of the home
improvement scheme and to the actual reduction
of the Chagas vector and disease in Guatemala
(Pellecer, M. et al, 2013).
5. ORGANISATION AND PEOPLE
The eco-health approach was founded and resides
within the Universidad de San Carlos, at the
Laboratory of Applied Entomology and
Parasitology (LENAP). This institutional location
helped them solidify alliances with key
international donors and agencies, as the backing
of a public university provides partners with
reassurance and institutional trust. Internally,
however, the lab team works in more organic
ways. Dr. Monroy, who has led the laboratory since
its inception, retired formally from the university
when reaching pension age some years ago, but
since then continues to work without a contractual
obligation. The university provides the
infrastructure and guarantees her access to
undergraduate and postgraduate students, while
the laboratory works on a project basis, and Dr.
Monroy helps the team ad honorem in securing
funds to continue with their home improvement
programme and to embark on new research
projects. More importantly, she supports them
with her academic and writing experience, as they
continue to publish articles and other type of
reports arising from their research. In the last two
years only, for example, Dr. Monroy has
coauthored more than 26 academic articles. Dr.
Antonieta Rodas, microbiologist, has also
supported the laboratory from its inception. Along
these two committed scientists, there has been a
steady educational process, whereby more than
90 researchers, mostly women, have participated
during their studies as young researchers and have
then pursued careers in science.
Under the shared leadership of Dr. Monroy and Dr.
Rodas, the team at LENAP understands and
practices team work. At interview, several of the
current researchers commented that
communication flows in all directions, giving them
the confidence to pose questions or discuss new
ideas or findings at any time with senior members
of staff. The laboratory operates with a lean
budget. Everybody who is employed at any given
time, on a project basis, receives a salary, and most
funds raised go to the implementation and further
replication of the eco-health and ecosystem
approach.
Dr. Monroy emphasizes that trust holds the lab
team together and this helps them build solid
relationships with other institutions: “I am convinced
that everything goes down to trust. People who work for
us trust what we do, they trust this approach and on how
it really transforms the lives of these communities. They
can see it when we visit the field. Communities also trust
us because we deliver, and we accompany them. The
more we visit them, the easier it gets to work with them.
And trust is also what allows building up inter-institutional
relationships. I can work with the Ministry of Health for
example, because after many years, there is trust
between us” (Maria Carlota Monroy, Director
LENAP).
5.1. COSTS CONSIDERATIONS
LENAP has been financially supported by different
international agencies such as the Japan
International Cooperation Agency (JICA) which
donated much of the equipment the laboratory
still uses, the World Health Organization (WHO),
the US based National Institute of Health (NIH) and
the National Science Foundation. However, the
main financier of the ecosystem approach to the
control of Chagas has been the International
Development Research Centre (IDRC) from
Canada, which in 2004 supported the idea that
new control strategies, beyond chemical
sprayings, were needed.
More than offering a summary of their financial
history, when consulted, the team explains clearly
their costings: “It costs approximately US$100 to fully
repair one house. Imagine what we could do with a $1m
donation. After paying our researchers who generate
new knowledge and after securing the salaries of our field
technicians, who do not carry out the improvements but
teach people and local communities how to do them and
accompany them in the process, we could be
transforming at least 8.000 homes for good. When we
support one family or when we improve one house, we
are improving the conditions not just for that generation,
but also for the following” (Maria Carlota Monroy,
Director LENAP).
Connecting the laboratory with a primary school in
New York, for example, allowed staff to start
providing groceries and other goods to those
patients undergoing treatment, something they
could not do before. This experience has pushed
staff to consider possible ways in which people not
just in Guatemala but worldwide can start
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sponsoring and donating to the home
improvement process. Ideas for social ventures
that would allow them to do that are currently
being explored and could eventually contribute to
the cost structure of the program.
6. OUTPUTS AND OUTCOMES
Before focusing on the impact of this programme
under the lens of the objectives that all social
innovations must achieve (Mulgan, 2015), some
outputs and other intermediary results are
discussed; these occurred as byproducts of the
home improvement strategy.
Belter Alcántara, field technician, refers to one of
them directly: “When people start participating from the
whole process, when they take part in every step of the
home improvement program, you can notice the effect it
has on their whole lives. They start showing interest and
pride. They move from looking down to looking us up in
the eyes. They move from the shame of having
´chinches´ in their house to invite us to enter their houses.
This programme takes people out of depression and lack
of hope and gives them a positive mindset” (Belter
Alcantara, Field Technician). Interviews with
beneficiaries of the strategy confirmed this
positive psychological impact.
As a result of visibly improving the homes, people
also start organising better outdoor areas. In this
regard, Dr. Monroy commented: “As we put so much
emphasis on taking the animals out of the house, people
start caring more about their outsides. We´ve noticed for
example that many of them planted new trees outside
their houses. Many women entered fruit growing and
cultivating, when they were not doing it before. They are
now selling mango, papayas, nances, lemons and other
fruits they did not produce before. We can say that
gender empowerment through economic independence
and better use of the land are also results of improving
their homes” (Maria Carlota Monroy, Director
LENAP).
With economic empowerment, better use of
natural resources, and stronger incomes for these
families, people have enjoyed better nutrition and
so better health. Another aspect of more trees
outside the homes is that there is more shade, and
houses are notably cooler than before. Apart from
more positive mindsets, better fed children and
families, and overall better conditions, other health
outcomes are associated with the home
improvement program. In the intervention areas,
by improving the condition of the floors and
moving the animals out of the house, there has
been a general reduction of intestinal parasite
infections in children (Stevens et al., 2015).
Geoff Mulgan (2015) affirms that all social
innovations fulfil three objectives, namely: the
creation of social value; the development of local
skills and abilities; and overall higher levels of
wellbeing.
The eco-health approach to Chagas disease has
created social value by reducing the vector´s
infestation rates, so reducing the levels of
infections, illness and deaths associated with
Chagas disease (Monroy et al., 2009; IDRC, 2014).
There has also been positive cultural and
behavioral change in the communities. Informing
and educating rural communities on how to
control the bugs by making simple improvements
to their homes has led not just to the reduction of
Chagas but to many community members feeling
empowered and in charge of their own progress,
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to higher levels of self-esteem, and to a more
positive sense about the future. The home
improvement programme is widespread in the
Jutiapa region, and when applied to an organised
community, its chances of being accepted, owned,
implemented and maintained are very high, as
word of mouth also plays a role in its
dissemination.
There is also good evidence of the development of
local skills and abilities. In Guatemala City, many
young science students have benefited from
joining a real research laboratory early in their
careers. One current student commented: “I came
here wanting to learn about molecular biology and
genetics. That happened fortunately, but here I learn also
about human and sociological perspectives, for which I
did not receive any training during my career. That
expanded my horizons. Genetics can really have much
broader implications than I thought” (Undergraduate
Student, LENAP). Local abilities have also grown
in rural regions in different ways. The field
technicians that LENAP hires, such as Belter
Alcántara -the entry and connection points with
local communities- have benefited not just from
learning about health, engineering, construction,
biology and agronomy but also from playing a
vital, life changing role in their communities.
Similarly, many of the peasant women and men
who benefited from the programme have
developed new skills and abilities: construction
skills to improve their own floors and walls,
agricultural abilities, and even entrepreneurial
talents. LENAP staff suggested and taught some
basic beekeeping skills to one group of women
back in 2012, for example, and these women now
sell honey and other products through a
collectively owned business.
The higher levels of wellbeing that this innovation
in health created are evident in different ways, as
discussed above. According to Dr. Monroy, in 1978
there were 38,000 cases per year of Chagas
disease, compared to 2000 cases documented in
2017 in the endemic zones of Guatemala. The
sense of a superior purpose that the field
technicians have experienced in the process of
empowering and educating communities also
contributes to higher levels of happiness. Feeling
good and motivated about one’s home and future,
and finding enthusiasm after experiencing apathy,
is another way in which this programme has
contributed to the wellbeing of rural populations.
The economic empowerment of women, and
others in the community, accompanying such
processes, is an added and unintended value.
7. SUSTAINABILITY AND SCALABILITY
The sustainability of the eco-health approach
depends on several factors. To make it sustainable
in social terms, it is important that rural builders
and people in general embed the lessons about the
right mix of local materials (which tend to be
cheaper than industrial ones and can vary from
one place to another) and knowledge about ways
of polishing and maintaining floors and walls inside
homes, while animals are kept outside. Other
agencies present and active in the regions need to
promote more actively the home improvement
strategy alongside their interventions, not
replacing them but accompanying them, as there
are many other actors such as World Vision, Care
International and the Universidad del Valle de
Guatemala trying to reduce the prevalence of
Chagas from different angles. For these purposes
and searching for financial sustainability, the team
at LENAP continues to fundraise to reach new
geographical areas and to continue to accompany
prior intervention communities through
community events, regular visits and workshops.
They also continue to build alliances, partnerships
and collaborations with other agencies, as
mentioned above, to embed more systematically
their strategy.
Stronger capacity building, and a training and
educational strategy that should be delivered at
(and adapted to) different levels and at national
scale, is desirable. Team members of the USAC
consider themselves ready to lead this. Groups of
people that could benefit directly from this
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strategy should include science students,
community and social workers, anthropologist and
sociologists, health professionals at all levels,
public health policy makers, workers of NGOs,
government officials such as majors and
governors, local schools staff and teachers, among
many others.
In terms of scale, this approach has already been
replicated by the project team in other countries
such as México, Honduras, Salvador and
Nicaragua. According to an IDRC Report from
2014, “the home improvements have led to dramatic
decline in infestation rates of T. Dimidiata. In Guatemala,
house infestation declined by a factor of four in
participating communities, while in study sites in
Honduras, the vector was completely eliminated from
households (…) In less than 18 months, almost 70% of
medium to high-risk houses were improved, with further
work still underway in El Salvador” (IDRC, 2014). Dr.
Monroy has estimated that to 2018, the
programme has improved 8000 homes in Central
America from its beginning, most of them in
Guatemala, benefiting approximately 40,000
people. Despite these numbers, the project team
considers that the levels of diffusion could be
higher, but Chagas in still a neglected disease that
does not break into TV news. The variations in the
availability of raw materials also plays a decisive
role in levels of diffusion. In Nicaragua, for
example, the materials exist, but they are at a
deeper level underground, and therefore it is more
expensive to access them.
The home improvement strategy and the
ecosystem focus could be shared and adapted to
the availability of local materials and to local
conditions in every country where Chagas is a
problem. But the leaders warn us, based on their
experience:
“Success for this approach depends on how organised a
community is and what levels of trust there are between
the communities and the champions of this approach. If
a community is fragmented, disorganised, failure is
guaranteed. If we don’t take time to select carefully which
person is a trusted messenger in each community, this
doesn’t work” (Interview with Dr. Monroy)
8. KEY LESSONS This team is welcomed in rural areas where they
have intervened, and this is testimony to the fact
that the strategy has changed the lives and
perspectives of their intended beneficiaries. Some
messages that emerge from this case study offer
insights for anyone working on neglected diseases
or other diseases of poverty:
• Health interventions should address risk
factors and not focus on effects. When the
attention is given to the root causes of health
problems, chances of solving them become real,
outperforming palliative responses.
• Communities need to be approached with
respect, and their culture must be taken into
account. Field workers and technicians have to be
accepted and trusted by communities, and they
should preferably come from those same areas, as
they function as knowledge brokers between
research laboratories and rural inhabitants. Once
the information is widespread, local people must
own the techniques, so they can implement them
by themselves and repeat them as needed.
• Interventions are more effective when
they involve multiple disciplines and when they are
designed to function across sectors. Working in
isolation as a researcher, or as the sole possessor
of a strategy as a team, will not resolve health
problems at a large scale.
• Effective health interventions tend to
unleash other positive dynamics, such as
empowering community members and identifying
13
new income streams that emerge as a result of
learning new skills and enjoying a better health.
• Creativity needs to be called upon in
terms of proposing new ways of funding these
participatory approaches. The eco-health one, well
designed and concrete in nature, is not necessarily
expensive, and consequently its scope and impact
could be multiplied, benefiting thousands more.
14
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Chavez, E (2015), Análisis de Chagas Guatemala 2015. Epidemiología, Ministerio de Salud Pública
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